Cough in children

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Marufa Marium, M.B.B.S[2]

Synonyms and keywords: Cough in kids

Overview

Cough is a common complaint of the pediatric population of the outpatient department. It is a natural reflex by which foreign and infectious particles are cleared through an involuntary expulsive force of air by the dynamic mechanism of respiratory airways. The word 'Cough' is derived from the 14th century Dutch word 'Kochen' and the high middle German word 'Kuchen'. Cough is classified under several categories. For example, duration of the complaint, nature or quality, anatomical location, etiology and grades of coughs. Stimulation to cough receptors provokes sensations of coughing through the afferent pathway via the vagus nerve, central respiratory centers in the upper pons and medulla, and efferent pathways via the phrenic and vagus branches. Differential diagnoses of cough are evaluated through identifying specific etiology, presenting symptoms, detailed history and findings of physical examination, laboratory, and imaging investigations. Some of the causes are emergently managed to reduce the mortality of a child.The mainstay of therapy for cough is supportive. Antihistamine, antitussive medications and nasal decongestant are provided for alleviating symptoms of acute cough. Allergic conditions are treated with steroids.

Historical Perspective

• The word cough was first derived from the middle English word 'Coughen' or old English 'Cohhian' which was primarily composed of the middle Dutch 'Kochen' and the high middle German 'Kuchen', in early 14th century.

Classification

• Cough in children may be classified or defined according to the duration of presenting complaints, quality and sound, and causes of cough into several groups.:
• 1 Duration of Presenting complaints: According to the duration of cough, it can be sub-classified into three categories:
  • Acute: < 3 weeks.
  • Subacute: 3 to 8 weeks.
  • Chronic: > 8 weeks.

• 2. Nature or quality and sounds: According to the quality and sound, the cough can be sub-classified in to following categories:
  • Dry or Hacking or Nonproductive.
  • Wet or productive cough.
  • Staccato or short repetitive cough.
  • Whooping or paroxysmal violent or spasmodic cough.
  • Barking cough: Brassy barking or Honking barking.
  • Phlegmy cough.
  • Burning cough.

• 3. Causes of Cough: Based on the causes, a cough is subdivided into following three subgroups:
  • Specific cough.
  • Nonspecific cough.
  • Expected cough or Normal cough.

• 4. Anatomic classification on the causes of a cough: A cough can be produced from different anatomical locations. For example:
  • Nose and Paranasal sinuses.
  • Pharynx.
  • Larynx.
  • Trachea and Bronchi.
  • Pulmonary parenchyma.
  • Pleura.
  • Mediastinum.
  • Heart and blood vessels.
  • External ear and Tympanic membrane.
  • Esophagus.

• 5. Grades of cough: Cough can be graded into four main sub categories:
  • Eutussia or Normal.
  • Hypertussia or Sensitized.
  • Hypotussia or Desensitized.
  • Dystussia or Pathological.
  • Atussia or Absent.

Cough in children can also be classified under infectious (Bacterial, Viral, fungal, Parasitic) or non-infectious categories broadly.

Pathophysiology

• A cough is a natural innate primitive reflex that helps in mucocilliary clearance of foreign particles and secretions from respiratory tracts. It is also a defense mechanism protecting the respiratory airways from aspiration of pathogens, particulates and secretions. A complex arc comprised of neuro-respiratory pathways helps in initiating the cough reflex.

Mechanical and chemical stimulation of cough receptors (RARs or Rapidly adapting receptors, C fibers or slowly adapting receptors) in Respiratory airways

Afferent pathways: Sensory nerve fibers via Vagus Nerve from ciliated columnar epithelium of upper airways, cardiac and esophageal branches from diaphragm send impulse to central cough center

Central cough center in upper brain stem medulla and pons send impulse of sequence of phases (Inspiratory, Compressive, Expiratory) for constituting cough

Efferent pathways: The nucleus retroambigualis sends impulse via phrenic and spinal motor nerves to diaphragm and abdominal and respiratory muscles, the nucleus ambiguous sends impulse to larynx by laryngeal branches of vagus nerve

• On gross pathology, bloody, serous , mucoid, rusty, pink frothy, and purulent are characteristic findings of sputum produced by coughing.
• On microscopic histopathological analysis, pathogens, RBCs, leukocytes, epithelial cells are characteristic findings of sputum produced by coughing.

Causes

Causes of cough in children according to duration:

According to quality and sound of cough in children, the causes can be classified according to the following chart:

Dry or Hacking or Nonproductive

Sinusitis, Tonsillitis, Pharyngitis, Allergic Rhinitis, GERD, Asthma, Environmental exposure to irritants(pollen, dust, mites, smoke), Post infectious cough.

Wet or productive cough

Cystic fibrosis, Bronchiectasis, Bronchiolitis, Tuberculosis, Rhinitis, Postnasal drip, Pneumonia, Emphysema, Acute bronchitis, Asthma

Causes of Cough based on Nature or quality and sound

Staccato or short repetitive cough

Chlamydia pneumonia

Whooping or paroxysmal violent or spasmodic cough

Pertussis

Barking cough

•Brassy barking: Croup, Tracheomalacia, Laryngitis, Tracheitis •Honking barking: Psychogenic cough , Tourette syndrome (habit cough)

Stridor

Viral Croup, Epiglottis, Bacterial tracheitis, Retropharyngeal and peritonsilar abscess

Burning cough

Bacterial Bronchitis, Irritants

Based on anatomical location the causes of cough in children can be demonstrated in the following chart:

Nose and Paranasal sinuses

Rhinitis, Foreign Body, Sinusitis, Nasal polyp, ppHypertrophied inferior turbinate]]

Pharynx

Pharyngitis, Foreign Body, Irritants

Larynx

Laryngitis, Epiglottis, Tonsillitis, Laryngomalacia, Subglottic stenosis, Foreign body

Trachea and Bronchi

Tracheitis, Croup, Bronchiolitis, Bronchiectasis, Bronchitis, Cystic fibrosis

Causes based on anatomic location

Pulmonary parenchyma

Pneumonia, Tuberculosis, Environmental toxin, Respiratory distress syndrome, Aspiration syndrome, Hypersensitivity Pneumonitis, Connective tissue disease, Alveolar capillary dysplasia, Neuroendocrine cell hyperplasia of infancy, Medications, Mutations causing surfactant dysfunction, Emphysema

Pleura

Pleurisy, Pneumothorax, Hemothorax, Parapneumonic effusions, Pleural tuberculosis, Congenital hydrothorax and chylothorax

Mediastinum

Mediastinitis, Mediastinal Tuberculosis, Thymoma, Thymic hyperplasia, Thymic carcinoma, Neuroblastoma, Ganglioneuroma, Non Hodgkin lymphoma, Sarcoma, Mature teratoma, Endodermal sinus tumor, Hemangioma, Wilms tumor, Lymphangioma

Heart and blood vessels

Congenital heart disease, Myocarditis, Heart failure, Cardiomyopathies, Wegener granulomatosis, Valvular heart disease, Vasculitis, Arteriovenous malformation

External ear and Tympanic membrane

Otitis media and externa, Impaction of foreign body, wax, Myringitis

Esophagus

GERD, Tracheoesophageal Fistula

Differentiating Cough from other Diseases

Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
			Symptoms							Physical exam
			Onset	Duration	Productive cough	Hemoptysis	Weight loss	Fever	Dyspnea	Physical Examination	Lab findings	Imaging	PFT	Gold standard
Respiratory	Upper airway diseases	Epiglottitis	Abrupt or acute	12−24 hours	−	−	−	+	+	Ill appearing child in Tripod posture Inspiratory Stridor Hoarseness / Hot-potatoes or Muffled voice Drooling, Tachypnea, Tachycardia Cervical lymphadenopathy, Erythematous pharynx and larynx	Elevated white blood count in CBC Blood culture may show bacterial growth Epiglottal culture in intubated patients may show bacterial growth	Enlarge epiglottis (>8 mm), loss of vallecular air space and distended hypopharynx as known as 'Thumb print' sign on lateral neck X−ray may be helpful	Normal function	Direct visualization of erythematous and edematous epiglottis	Tripod posture Drooling Tenderness of the anterior part of the neck Etiology: Haemophilus influenzae
		Croup	Acute	3−5 days	+	−	−	+	+	Stridor Crackles	Leukopenia	Subglottic narrowing (steeple sign) in postero−anterior radiograph chest	Decreased tidal volume	Clinical diagnosis. Laboratory findings and imaging are not necessary for diagnosis	Barking cough Etiology: Parainfluenza virus type 1 (most common)
		Pertussis	Acute	Two weeks	+ Whooping sound	−	+	+	+	Clear chest	Polymerase chain reaction (PCR) shows Bordetella pertussis Serologic testing	Atelectasis may seen on chest imaging Lymphadenopathy	Normal function	Culture	Etiology: Bordetella pertussis Phases: Catarrhal, paroxysmal and convalescent
		Common Cold	Acute	3−10 days	+	−	−	+	−	Rales Wheezing	Bacterial culture is not indicated	Chest X−Ray in patients with signs of consolidation	Normal function	Clinical diagnosis	Conjunctival injection Nasal congestion
		Tonsilitis	Acute or Acute Recurrent, Chronic	Varies	+(Mucus from inflamed tissue)	−/+	−	+	Odynophagia, Tachypnea	Stridor Hoarseness of voice/ Dysphonia Cervical Lymphadenopathy	Rapid Antigen Detecting Test Throat Swab Culture EBV Heterophile Antibody Test Monospot Test Complete Blood Count	Chest X−Ray shows normal finding. USG may show Peritonsillar abscess.	Normal function	Rapid Antigen Detecting Test	Etiology: Rhinovirus, Adenovirus, Respiratory Syncitial Virus, Influenza Virus, Corona Virus, Group A streptococci
		Seasonal Influenza	Acute	Upper respiratory tract symptoms with fever peaking at three to four days, resolved by seven to ten days.	−	−	−	+(High grade)	+	Fussiness, Vomiting, Diarrhea, Myalgia, Focal wheezing, Rales, Tachypnea, Tachycardia, Retractions, Seizures	RT−PCR Virus culture Rapid Influenza diagnostic test Immunofluroscence-Direct or indirect Antibody testing	Reticular or reticulonodular opacities in chest X−Ray	Normal function	Clinical diagnosis	Etiology: A or B Influenza virus
		Sinusitis	Acute, Subacute, Chronic, recurrent	Acute: < four weeks Subacute: four−twelve weeks Chronic: > twelve weeks Recurrent: > four episodes / acute episode of rhinosinusitis yearly.	+	−	−	+	+	Restlessness, Nasal Congestion, Post Nasal Drip, Facial Pain, Rhinorrhea	In complicated acute bacterial rhinosinusitis, endoscopic cultures or sinus aspirate is indicated Nasal culture may also be helpful	Air−fluid level, mucosal edema and bony erosion of sinus on CT MRI for distinguish the etiology	Normal function	Clinical diagnosis: Nasal congestion and Post Nasal drip , obstruction, and purulent rhinorrhea	_
Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
			Symptoms							Physical exam
			Onset	Duration	Productive cough	Hemoptysis	Weight loss	Fever	Dyspnea	Physical findings	Lab findings	Imaging	PFT	Gold standard
Respiratory	Lower airway	Asthma	Chronic	Years	+ Clear mucoid or yellow sputum	−	−	−	+	Wheezing (expiratory) Rales Rhonchi	Eosinophilia Total serum IgE in test for allergy may be helpful	Normal airways in chest X−ray CT if there any abnormality in chest x−ray	FEV1/FVC ratio <70% and FEV1 >15% increase after 15 minutes of 2 puffs of beta 2 sympathomimetic drug After physical active FEV1 decreases by >15% After inhaled corticosteroid (ICS)FEV1 increased by >15%	Airflow limitation on spirometry	Family history Seasonal variation
		Bacterial Protracted Bronchitis	Chronic	At least four weeks	+(Purulent)	−	+	+/−	+	Wheezing Rhonchi	Sputum culture is not indicated PCR in bacterial infection may be helpful	Chest x−ray to exclude other diseases	FEV1 < 80%	Clinical diagnosis	Majority of cases are caused by Streptococci Pneumoniae, Hemophylous Influenza, Staphylococcus aureus
		Bronchiectasis	Chronic	Months to years	+ Mucopurulent sputum	+	−	−	+	Crackles Wheezing Shortness of breath Chest Pain	Complete blood count (CBC) Sweat Test, CFTR Gene analysis Ciliary motility test, Nitric Oxide Test, Ciliary structures, Genetic Testing IgG, IgM and IgA Sputum culture for fungi, bacteria and mycobacteria	Linear atelectasis and dilated airways in chest x−ray Bronchoscopy, Upper GI Endoscopy, MRI/CT will provide information of other etiologies.	FEV1/FVC <70% Normal FVC Low levels of FEV1	CT of chest	Digital clubbing Recurrent pleurisy
		'Foreign body aspiration	Acute	Sudden Onset	+	+/-	−	+/-	+	Wheezing, Inspiratory or Biphasic Strioor Unilateral Decreased breath sounds Cyanosis	No specific tests	Hyperinflated lungs, atelectasis, and mediastinitis Shift in chest radiograph when the object is radio−opaque CT may be helpful	Not specific	Bronchoscopy	In children <1 year Organic materials in children
		Bronchiolitis	Acute	8−15 days	+	−	−	+	+	Rhinorrhoea Cyanosis, Hypoxia Intercostal and subcostal retraction Tachypnea Wheezing Crackles Grunting and Nasal Flaring	Complete blood count (CBC) may be helpful Urinalysis & urine culture ( in infants)	Chest x−ray may be helpful	Normal function or obstructive changes (FEV1/FVC <70%) Air trapped in Lungs Decreased Diffusing capacity of Carbon Monoxide ( DLCO)	Clinical diagnosis	Etiology: Respiratory syncytial virus, Rhinovirus Children <2 years
Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
			Symptoms							Physical exam
			Onset	Duration	Productive cough	Hemoptysis	Weight loss	Fever	Dyspnea	Physical Examination	Lab findings	Imaging	PFT	Gold standard
Respiratory	Lung Parenchyma	Pneumonia	Acute		+	−	−	+	+	Crackles Egophony Decreased bronchial sounds, Rhonchi Rapid Breathing Intercostal retractions Nasal Flaring, Grunting Tachypnea, Tachycardia Vomiting	Leftward shift leukocytosis Blood culture in hospitalized patients Sputum culture in hospitalized patients	Consolidation, cavitation, and infiltrated interstitial in chest x−ray Anatomical changes observed in chest CT	Not specific	Infiltration observed in chest x−ray	Community−acquired pneumonia Healthcare−associated pneumonia
		Tuberculosis (TB)	Chronic	Weeks to months	+	+	+	+	+	Pleural effusion Crackles Whispered pectoriloquy Decreased fremitus Rhonchi	Sputum AFB stain may be +. Mycobacterium Tuberculosis culture may be + Molecular testing may be helpful	Reactivation of TB is observed as infiltration in the upper lobe in chest x−ray	Decreased FEV1 Reduced FVC	Isolation of Mycobacterium tuberculosis	Etiology: Mycobacterium tuberculosis
Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
			Symptoms							Physical exam
			Onset	Duration	Productive cough	Hemoptysis	Weight loss	Fever	Dyspnea	Physical Examination	Lab findings	Imaging	PFT	Gold standard
Cardiac		Cardiac Failure	Acute	Hours	−	−	+	−	+	Crackles Increased respiratory rate, retraction Wheezing, Grunting, Nasal flaring JVD Displacement of apex beat Gallop rhythm, Murmur may present. Hepatomegaly, Ascites	The following investigations may be helpful: Arterial blood gas BUN Serum creatinin Serum troponin Electrolytes Lactic acid Complete blood count	Cardiomegaly, interstitial edema, alveolar edema, Pleural effusion and blood redistribution in lower lobes in chest x−ray	Not specific	Clinical diagnosis Tests are supportive	12−lead ECG Plasma BNP and NT−proBNP Echocardiography
		Congenital Heart Disease	Acute or Chronic	Variable	+	+	−	−	+	Crackles Hoarseness	Not specific	Electrocardiogram may be helpful Enlargement of left atrium and appendage in chest radiograph	FVC reduced	Resting transthoracic echocardiography	Stress testing Cardiac catheterization
Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
			Symptoms							Physical exam
			Onset	Duration	Productive cough	Hemoptysis	Weight loss	Fever	Dyspnea	Physical Examination	Lab findings	Imaging	PFT	Gold standard
Gastrointestinal		Gastroesophageal reflux	Chronic	Variable	+	−	+	−	+	Wheezing Hoarseness Regurgitation, Vomiting Back Arching, crying *Apnea Epigastric pain	Not specific	Upper endoscopy may be helpful Barium esophagram may be helpful	Normal function	PH testing	−−

Epidemiology and Demographics

• A cough is one of the most common presenting symptoms of children in the outpatient department.
• Ninety percent of acute coughs in children are resolved within three weeks. The prevalence of chronic cough in children is approximately 5% to 10% in the USA according to the American Academy of Pediatrics.

Age

• Cough is more commonly observed among children under 5 years of age.

Gender

• Boys are more commonly affected with cough than girls.

Race

• There are racial predispositions for certain causes of cough in children. Asthma is predominant in Blacks and American Indians or Alaska natives while Cystic fibrosis, Wegener's granulomatosis more frequently affect Caucasians according to the American Lung Association.

Risk Factors

• Common risk factors in the development of a cough in children are:
  • Preterm birth and delivery by caesarian section.
  • Respiratory Distress Syndrome.
  • Congenital Heart Disease.
  • Age less than 1 year.
  • Maternal Influenza vaccination.
  • Malnutrition.
  • Secondary exposure to tobacco smoke.
  • Air pollutants, Mold, Inadequate ventilation.
  • Immunodeficiencies.
  • Daycare attendance.
  • History of Atopy.
  • Household pets.
  • Low socioeconomic status.

Natural History, Complications and Prognosis

• The majority of patients with acute cough have recovery within three weeks in 90% of cases. Some cases are progressed to subacute and chronic phases. Chronic cough lasts more than eight weeks whereas recurrent cough can affect a child for more than two years with 1-2 weeks duration in each episodes.
• Early clinical features include frequent episodes of coughing, runny nose, sneezing, low grade fever, sore throat, night sweats, arching back, irritability, failure to thrive, fussiness, and a choking sensation(foreign body impaction).
• If left untreated, acute cough can cause following the complications in children:
  • Otitis Media
  • Rash
  • Vomiting
  • Diarrhea
  • Bronchitis
  • Pneumonia
• Chronic cough can progress to-
  • Inability to sleep
  • Bronchospasm
  • Dizziness/ Syncope
  • Pneumothorax
  • Pneumomediastinum
• Rib fracture

• Prognosis is generally excellent and efficiently treatable in most of the etiology of cough in children.

Diagnosis

Diagnostic Criteria

• Diagnosis of causes of a cough is made after a detailed history, presenting complaints and physical examination and laboratory findings in some cases. Cough can be classified according to:
  • Duration.
  • Nature or quality of cough.
  • Etiology.
  • Anatomic location.
  • Grade.

A detailed history focusing on onset of disease, factors worsening the episodes, time of worsening, alleviating factors, amount of work to breathe, presence of shortness of breathing, relation with vomiting, food intake, posture, presence of blood, systemic findings (fever, weight loss, hypotension, syncope, vertigo, dizziness, failure to thrive), episodes of choking, household socioeconomic status, family history, vaccination history, drug abuse and smoking in family members, atopy, antenatal, perinatal, postnatal, birth history, developmental history, feeding history.

The following signs are alarming which need further emergent evaluation by the physician:

• Cyanosis or hypoxemia or hypoxia
• Respiratory distress
• Stridor
• Toxic appearance
• Weight loss

Symptoms

• Cough may be associated with the following depending upon the cause:

• Breathlessness and episodes of coughing
• Sneezing
• Fever
• Sore Throat
• Night Sweats
• Arching Back
• Irritability
• Failure to thrive
• Fussiness
• Choking sensation(Foreign body impaction)
• Chills and Rigor
• Wheezing
• Headache, myalgia, fatigue

Physical Examination

• Patients with cough are usually restless, irritable, fussy. Children with severe respiratory distress usually are toxic and cyanotic in appearance. Presence of grunting, nasal flaring, intercostal or subcostal retraction or accessory muscle usage needs prompt evaluation.
• Physical examination may be remarkable for:

• Vital signs: Documentation according to patient's age
  • Blood pressure
  • Temperature
  • Respiratory rate
  • Heart rate

• • Growth charts and developmental milestones: weight, height, length, occipitofrontal circumference
• General Appearance: Level of consciousness, Cyanosis, Distressed or ill-appearing, hydration and nutritional status.
• Skin: Turgor, color, texture, rashes or any other abnormal findings.
• Lymphatics: Lymphadenopathy, location, number and size, consistency, adherence to underlying structures.
• Head: Size, shape, fontanelle, overlapping suture, scalp, hair.
• Eyes: Lacrimation, redness, irritation, conjunctival injection, periorbital redness.
• Ears: Position of ears along with external auditory canal, tympanic membrane visualization.
• Nose: Any deviation of nasal septum, normal or hypertrophied inferior turbinate, nasal polyps and congestion, nasal discharge, tenderness over sinus point.
• Mouth and throat: Look for any associated abnormality
  • Lips: Color, mucosal abnormality and congenital lesions.
  • Buccal mucosa: Hydration, Color, Presence of anomaly.
  • Tongue and teeth and gum: Developmental anomaly, Color, papillae.
  • Palate: Anomaly, arch.
  • Tonsils: Color, size, any membrane, calcification and exudates.
  • Posterior pharyngeal wall: Color, appearance.
  • Gag reflex: Intact or not.
• Neck: Thyroid, trachea position and examination, any cystic or nodular masses, presence of nuchal rigidity.
• Respiratory:
  • Inspection: Breathing pattern (abdominal and periodic), respiratory rate, accessory muscle usage, chest wall shape.
  • Auscultation: breath sound symmetry, vesicular, bronchial, rales, rhonchi, wheezes, stridor.
  • Percussion: resonance, hyper resonance and dull.
  • Palpation: trachea position, tactile fremitus.
• Cardiovascular: rhythm, murmur, any radiation of sound, pulse in both extremities.
• Gastrointestinal: Shape of abdomen, Umbilicus, Bowel sounds, Palpation to evaluate any organomegaly or masses or rebound guarding.
• Musculoskeletal: Aching back, scoliosis, lordosis, kyphoscoliosis, swelling and tenderness in any muscles, joint, clubbing, edema, deformity of extremities, gait and posture, any sign for hip dysplasia.
• CNS: Primitive reflex, superficial and deep tendon reflex, strength and tone of muscles, cranial nerve examination.
• Genitourinary: Presence of external genitalia deformity , hydrocele, cryptorchidism or hernia.

Laboratory Findings

• There are no specific laboratory findings associated with cough. Laboratory tests are done to differentiate the causes of cough in children.
• Complete Blood Count
• Arterial blood gas analysis
• Culture of nasopharyngeal swab and broncho alveolar lavage
• Gross and microscopic analysis and culture of sputum
• AFB testing and tuberculosis screening
• Allergy test
• Serum Immunoglobulins, autoantibodies
• Sweat test
• Exhaled nitric oxide test
• Esophageal pH
• Serology for Pertusis, CMV, Chlamydia, HIV.

Electrocardiogram

An ECG may not be helpful in the diagnosis of congenital heart disease, myocarditis, valvular heart disease, in children.

X-ray

Anterior/posterior view, lateral Chest and neck x-ray may be helpful in the diagnosis of causes of cough in children for: Pneumonia, Croup, Bronchitis, Epiglottitis, Foreign body impaction etc. X-ray of paranasal sinuses helps in diagnosis of sinusitis, deviated nasal septum.

Echocardiography or Ultrasound

Echocardiography/ultrasound may be helpful in the diagnosis of causes of cough in children. Echocardiographic findings aide in the diagnosis of congenital heart disease, whereas USG findings can help in evaluating complications like peritonsillar abscess, retropharyngeal abscess promptly.

CT scan

The High resolution CT is used for diagnosing causes of chronic cough in children such as bronchiectasis. Sometimes it helps in identifying congenital heart and lung anomalies.

MRI

A Chest MRI may be helpful in the diagnosis of the dynamic function of airways disease.. MRI can provide detailed findings of perfusion, ventilation mechanism of lungs and diaphragm. It can show oxygen enhancement, congenital anomalies too.

Other Imaging Findings

Other imaging techniques are used to evaluate causes of cough in children.

• Flexible Bronchoscopy
• Barium esophagram.
• Angiography

Other Diagnostic Studies

Other investigations done to rule out differential diagnosis of cough in children are:

• Spirometry for evaluating pulmonary function test.
• Bronchodilator provocation test.
• Ciliary function test.
• Genetic analysis for CFTR mutation, Primary ciliary dyskinesia etc.
• Video fluoroscopic or endoscopic swallow evaluation.
• Environmental assessment.

Treatment

Medical Therapy

• The mainstay of therapy for cough is supportive. Management of acute and chronic cough in children can be provided in the following sequences:
• Identification of etiology of cough and emergently manage the emergency condition such as foreign body impaction, severe respiratory distress, apnea with maintenance of airways, breathing, circulation.
• General measures with adequate hydration, nasal airway clearance with normal saline, reducing fever with antipyretics are done to give comfort to the child.
• Medical management:
  • Antihistamine, antitussive medications and nasal decongestant are provided for alleviating symptoms of acute cough. Allergic conditions are treated with steroids.
  • Bronchodilators (Ipratropium bromide, Albuterol, Salmeterol, Salbutamol), Antibiotic (Amoxicillin/Clavulanate, Cephalosporins, Respiratory fluoroquinolones, Antiviral, Antifungal, Antiparasitic) are used according to evidence-based management of particular causes of cough in children.

Surgery

• Some surgical procedures are performed for patients with Tonsillitis, adenoid hypertrophy, severe cases of laryngomalacia, tracheoesophageal fistula, congenital heart disease, complications of any disease or trauma in ear, nose, sinuses, pharynx, larynx, trachea, bronchus, lungs, and ribs.

Prevention

• Effective measures for the primary prevention of cough include:
  • Caregivers should be given health education on pros and cons of vaccination, alarming features of cough.
  • Physical hygiene including airways of an infant or a child should be maintained to prevent complications.
  • Head should be raised to prevent irritations in throat.
  • Humidified air will help clearing the sputum easily.
  • Adequate hydration to prevent formation of dry sputum.
  • Avoidance of triggers in case of atopic patient.
  • Nutritional balance should be maintained for rebooting the immunity.